29 yo M w/ h/o ulcerative colitis, basal cell carcinoma and metastatic melanoma who presented to ED for diffuse HA, nausea, transient visual disturbance
(flashing lights in L upper visual field), transient L hand numbness + tingling, speech difficulty and acute onset confusion.

HTN
Nephrolithiasis
Ulcerative Colitis
Basal Cell Carcinoma s/p resection
Metastatic Melanoma w/ known brain, lung, chest wall, lymph node, thigh and gluteus involvement s/p numerous biopsies + resections and treatment w/ IL2, aflibercept, dendritic cell vaccine +/- interferon booster and pembrolizumab

Ativan (parodoxical agitation)
Vitamin B6, Vitamin B12, Vitamin D, Vitamin E, MV,
Dexamethasone Taper, Keppra 1000mg BID,
Mesalamine 4800mg QHS, Zofran PRN, oxycodone PRN
Lives w/ wife. No smoking, alcohol or illicits.
Mother: Prothrombin Gene Variant w/ h/o DVT/PE
Maternal GM: Breast Cancer @ 55

VS: 37.2, BP 143/90, HR 98, RR 17, O2 Sat 97% RA
MS: Alert and oriented x 3, Agitated, Repetitive/slow/ labored speech, Follows simple commands
CN: VFs intact, PERRL, EOMI, No facial asymmetry
MOTOR: 5/5 strength throughout
SENSORY: Intact to light touch throughout
REFLEXES: 2+ biceps/triceps/patella/achilles, No ankle clonus, No Hoffmans
COORDINATION: ?
GAIT: ?

….of confusion, diffuse headache, nausea, speech difficulty (sounded like it was mostly expressive), L hand numbness/tingling and L upper VF flashing lights.

Received 10mg IV Decadron and 25g IV mannitol in ED, and was admitted for further management. He was continued on Decadron 4mg IV 6 hours and returned back to baseline 24 hours after admission. He was d/ced on dexamethasone slow taper w/ instructions for repeat brain
MRI in 1 month.

2 months later, he presents w/ acute abdominal pain. It was initially tolerable but progressed to stabbing, 10/10 pain that was not responsive to oxycodone. CT abdomen revealed L renal vein thrombosis and diffuse metastatic disease. He was initially placed on heparin gtt which was stopped b/c of his known hemorrhagic metastatic brain lesions. He underwent repeat neuroimaging.

• MRI ETC:

3 days after admission, abdominal pain acutely worsened. CT abdomen revealed free air and small bowl perforation. Not a surgical candidate b/c of hemodynamic status. The next day, he arrested (?2/2
PE) requiring 30 minutes of CPR for ROSC. He was intubated and maxed out on 3 pressors. Given poor prognosis, he was made CMO and expired.

Well-demarcated lesions
Variable amount of pigmentation
Could be hemorrhagic and necrotic
Pleomorphic Melanocytes
Mitosis
Necrosis
Staining + for S-100, HMB-45, Melan-A